9 SOUTH ST - BUILDING INSPECTION IMMMIS$ 1MOE fi IA1111 019 0PPROVE0 f3Y Tw
MPFC'IOB PWR TD A'.MNW B,EM QRAWkD
CITY OF SALEM
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BU LDW PEiMU APPLMTM FM
Permit to:
(Ckde whit l awr apply) Roof, Reraof, irate Cofatrta D"r. &W, Paul.
77
R�paiNRsplaoe. ouwr �ee c� w n a.
PLEASE I"OLR UEOIBLY A COMPLflMY TO AVOID DELAYS W PROCEpINp
TO THE INSPECTOR OF BUILDINGS: '
The undarsiprrd hereby appbs for a permit to tadid acoorditto the,foMowkrp
Nam: I
Owners Name GG� . t� /k 2o-S/ Z`
Address A Phone C Soy�t�
ArchkWs Name
Address & Pharfe
Mechanics Name Pe Je 'l a rjlrt s 4��cTo.- /a • xc.
Address & Phone s // (4n 1 wAs'/y7
ww b ft P" M cf bWbnp9 ® GtJGGy�o w /«Dlace�szv u
mdeft d kaw N a dwWq,for how mmy lw~
we kaft cedar to l (.7 e-3
t�frrwcd ooM Soap aN um r / sets 5 51
aMs L*se.....t
Lsc. I(y
Sowwh.of
iD LNi1DER THE PENALTY'
DESCRIPLION OF WORK TO U DONE PNhNlRY
l�!'lilCJy2 �k �s ���� L�Jlar/�ou1S Ah/��w.S��
MAIL PERMIT M. LI sou-4 sleee-IC
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� l.oe!�'mmoiuutaa!!h OfI �- `�a:[hudsl�d
boo W..L 16S"
tce.or &.1., 02111
c.wsa.. •
Workers' Compensvidn lumna AffUl ►k rr
,I, C �esdG ,c r( rf,.J�• or -to QC�7'oe Co l NC
. . whit.a prkcfpal pbce of bodaeo so
4- C�� .t/e-L� V►'� �— lac ��
M1
do heteby•cerdly under t1s�pdal�tW and pewildes of pwf.m doC .,,�yL�
I an an employer providing workers' compensation covepte for my anploYees `.o.^� am
tli rrw
1phe .lcaw Ame I co '. ll/C 7Cp 9-/a. - -7
Inrurance Cempq Poky Number
I an a sok proprietor and haw no one working fd►no in any caoadsy.
0 1 am a sok proprietor, general contractor or homeowner (drek oars) 1111111 leave Died ties
cornnttots listed below who haw the following workers' couMmnsadOe polices
convocuirInsursncet Conpatry/Po Nuntbw
Comraaer Insurance Company/Folicy Nuaier
Contractor Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
I r..ura"ace taef e(I* 4� r
e ii hnadaMom a/dw MA IV co.erapr.edoaee a.a ee.her.U M="
S"Wap ai rrew,e•eew A 152 w�i..of�f cads te.wint of a 1..el m ea•s I.f0000 eeYe►ar
r•ns•wwwwo ma a . w ice WORK ORAOE age. of 1100.00 a as J"ba As.
Signed this . of G o?3 —
�� ,/q
:icersceiFermittee 'Nolan{ Depart ent
uctnsinf Ecare
Soleesmens Office
=talth Deprrrrler,:
a PUSUC PROPERTY DEPARTMENT
.� 120 wAi"ImaTom STRERI SRO FLOOR
SALD%MA C t Y70
Tat-(978)746-MM EIIT.a!O
FAX (W741)7404N"
STANLEY J.YUSOVWZ.JlL. ----- - " - --
MA
DISPOSAL OF DE M AFFIDAVIT
In accords=wi&the psovisicns of MM c 4%SK I aclmoarl p do a s coodltiaa
of BuDdinS Permit/ .A debris melbas from the omamcd=ubvlty
Soveraed by this Bm'ldint Pelmit dM be disposed of in a properly Hoeosed soHdwmb
disposal facribty.no defined by MM c UL Si
Tba ofst: v2 2
Locahm ofFAmMy
,� a3
SisostareafP Appliaot .
FULLY conWhft
(PLEASE PRINT CLCLEARRLY) .
e G. Ids a/e-
ame ofPwoitAppHcsW
Fam Nsm%if say
Address.Caen-
Soft
Mw above stsdrte requires that debris from the demolitioj% rmovadoo,rehab or other
Arsdon of bm'l ft or sbucdae be disposed is it prvpaly hcand sogd-waste diip"
facility as deEiaed by MOL.cl% S1504 ad the buildms Permits or lac==m to
iudreate the besdon of the Lamy.